1. OUR ROAD TO PCMH RECOGNITION
Baldwin Family Health Care

2. Russ Kolski RN Strategic Projects Director Background in
Quality Management
Safety and Compliance
Accreditation (Joint Commission / AAAHC)
Given Medical Home Responsibility in July 2011
PCMH Accreditation
Meaningful Use
Pay for Performance
(Not my only role)

3. Baldwin Family Health Care
Health Center since 1967
Rural Area
Serve West Central Michigan
5 Medical Locations
3 Locations with Retail Pharmacies
3 School Based Health Centers
25,000 Annual Medical Visits
PCMH Status as of 2011
AAAHC Recognized for PCMH
BCBS Recognized for PCMH at 2 of 5 locations

4. Baldwin Family Health Care
Referral Tracking Moved to Registry
July 2012
HRSA Quality Funding
September 2012
Last Site Live NextGen EHR
June 2012
Hired Added Quality Staff
May 2012
Education MU Stage 2
April 2012
Report Development Registry Enhancement
Oct – Feb. 2013
Participation in ACO
February 2013
PCMH Steering Comm.
October 2011
PCMH Weekly Workgroup
August 2012
NCQA PCMH Submission Pt. 2
December 2013
NCQA PCMH Submission Pt.1
June 2013
Pre-Visit Planning
for All Patients
March 2012
Annual Training PCMH Module
November 2012
Implemented
i2i Tracks Registry
January 2012
Transition to Open Access
October 2011
Staff Training (Familiarization)
November 2011
MiPCT / CMS Demonstration
October 2011
HRSA PCMH Demonstration
September 2011
Dedicated Lead Selected
June 2011
Trial Staff Huddles/Pre-plan
November 2011
LEAN Event Staff Work Flow
November 2011
Implemented Quality Dept.
January 2012
MiPCT Case Managers Hired
January 2012
Submitted
MU Year 1
January 2012
First Site Live NextGen EHR
December 2011
Road to
NCQA PCMH Started 2011

5. “If we keep doing what we are doing, we will keep getting what we got
Yogi Berra

6. Personal PCMH Learning
Limited Understanding at Start
Attended PCMH Seminars
Local PHO
Michigan State Medical Society
Obtained Chronic Care Professional Certification
Reading
LEAN – Toyota Production System
TransforMed
IHI
PATH

7. Internal Planning EHR Transition (1st site live 12/2011 – last 6/2012)
Provider Coordinating Committee
Transition Committee
Established PCMH Steering Committee
Education at all levels
Visit Workflow Re-design
Transition from Acute Care to Preventative / Wellness Based Care
Match pre-EHR Provider Productivity
Integrate PCMH Elements into Standard Work

8. Steering Committee Membership
CEO (Ex-Officio)
PCMH Lead
Quality Manager
Chief Medical Officer
Physician Lead for EHR
Mid-level Provider
COO / Privacy Officer
Site Facility Manager
Finance Representative
Dental Representative*
Behavioral Health*

10. “Every system is perfectly designed to get the results it gets.”
Paul B. Batalden MD
Co-founder Institute for Healthcare Improvement
Founding Director Center for Healthcare Improvement and Leadership – The Dartmouth Institute

11. New Structure Eliminate Medical Support Specialist Role at 5 sites
Former Diabetes Registry Coordination (Old PECS System)
Centralize Registry Function within Quality Department
Added Quality Department Staff
PCMH Registry Specialist – May 2012
PCMH Report Generator – May 2012
Care Managers for 2 locations (MiPCT) – January 2012
CMS Muliti-payer Demonstration Project
Create PCMH Lead at each site – May 2012
Additional responsibility for selected staff member

12. Planning Tools Annual Performance Improvement Plan
Schedule of Activities
Comparison of Clinical Quality Measures for UDS/MU/PCMH/Pay for Performance Measures
Crosswalk between NCQA and BCBS PCMH Standards
Working examples will be shown at end of presentation

13. Annual PI Plan Activity

14. Activity Schedule Clinical Quality Indicator Reporting
January
UDS
ED Visits
Open Access
Framework for Clinical Portion of Annual PI Plan
February
Record Audit
7 Day post Hospitalization
Visits with PCP
March MU
Generic Rx Rate
Patient Self Mgt.
April
May
June
July
August
September
UDS/MU
October
PH Medications
November
December
Monthly Patient Contact Schedule
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Diabetes
Well Child
Immunizations 7-12
Chlamydia
Cardiovascular
Smoking Cessation
HTN
Well Child - Years / Lead
Immunizations - 15 Mo
Pap/Mam
Osteoporosis / RA
BMI
Asthma
Well Child - 3 to 6
Immunizations 3 - 6
Colonoscopy
COPD
Chronic Kidney

15. Periodic Assessment - BCBS

16. What Needs Measured?

17. Goal Comparisons

18. Periodic Assessment - NCQA

19. NCQA Report Priorities

20. Data Location and Reporting

21. NCQA Reporting

22. Evidenced Based Care - MQIC

23. Protocol Creation / Modification

24. Staff / Patient Tools PCMH Brochure
Care Management / Self Management Documentation
Standardized Work Documentation
Staff Education Tools

25. PCMH Brochure

26. Care Planning

27. Create Staff Documentation

28. Success’ NextGen EHR Implementation i2i Tracks Registry Implementation
Centralized PCMH Functions
Mailings for all sites using fold and seal mailers
Report processing and distribution
One Time download of all immunization in State Immunization Registry (MCIR) to our EHR
PCMH Module in Annual Competency Training
Planning
Worked Smarter, not Harder
Made sure Measures met multiple goals

29. Weak Areas (Failures) Open Access Scheduling Internal CAHPS Surveying
Competing Priorities
Internal CAHPS Surveying
Costly
Time Consuming
Interfaces
MCIR Upload
Identification of Managed Care Population
4 different attempts
Too Large – Wrong Measures – Too Small – Just Right
Provider Engagement
Competing Priorities (Productivity / EHR / PCMH)

30. Pearls Education Change is Difficult
Leadership (Administration and Board)
Provider
Staff (Clinical and Support)
Change is Difficult
Changing to the Chronic Care Model is More Difficult than meeting the NCQA PCMH Standards
Staff and Providers do not want to give up the old way
Competing Priorities
Care Management Population Selection
What is your time frame to meet goal? – Work Backwards
What percent of your proposed patients are seen during that time?
Who will do Care Magement?

31. Pearls Registry Standardize
Data Validation
How will you measure various aspects of care?
Will your registry report on those items?
Success is tied to staff proficiency with EHR.
Standardize
What will be documented where?
Who will perform specific ongoing reporting tasks?
Adopt the “Everyone works to their highest level of licensure or training” philosophy.
Live the “Triple Aim” and immerse yourself in PCMH

32. Pearls Communication Investment Flexibility Newsletters
Reference Materials for Staff
Investment
Financial (Registry / Licenses / Education / Staffing)
Staff Time (Education / New Tasks / Learning Curve)
Flexibility
Modify timeline as needed
Ask for help

33. Success? NCQA PCMH Designation at all 5 sites
Meaningful Use Payments for Stage 2 (2014)
Reporting
Valid Results
Available for all known measures
Trending data available
Improved Quality Scores
UDS
Pay for Performance Indicators – All Payers
Gain Sharing with our new ACO Initiative